Nipple Margin Research Articles

Positive Nipple Margins in Nipple-Sparing Mastectomy: Management of Nipples Containing Cancer or Atypia.

Nipple-sparing mastectomy (NSM) is an oncologically safe approach for breast cancer treatment and prevention; however, there are little long-term data to guide management for patients whose nipple margins contain tumor or atypia. NSM patients with tumor or atypia in their nipple margin were identified from a prospectively maintained, single-institution database of consecutive NSMs. Patient and tumor characteristics, treatment, recurrence, and survival datawere assessed. A total of 3158 NSMs were performed from June 2007 to August 2019. Nipple margins contained tumor in 117 (3.7%) NSMs and atypia only in 164 (5.2%) NSMs. Among 117 nipple margins that contained tumor, 34 (29%) margins contained invasive cancer, 80 (68%) contained ductal carcinoma in situ only, and 3 (3%) contained lymphatic vessel invasion only. Management included nipple-only excision in 67 (57%) breasts, nipple-areola complex excision in 35 (30%) breasts, and no excision in 15 (13%) breasts. Only 23 (24%) excised nipples contained residual tumor. At 67 months median follow-up, there were 2 (1.8%) recurrences in areolar or peri-areolar skin, both in patients with nipple-only excision. Among 164 nipple margins containing only atypia, 154 (94%) nipples were retained. At 60 months median follow-up, no patient with atypia alonehad a nipple or areola recurrence. Nipple excision is effective management for nipple margins containing tumor. No intervention is required for nipple margins containing only atypia. Our results support broad eligibility for NSM with careful nipple margin assessment.

Safety of Atypical Ductal Hyperplasia at the Nipple Margin in Nipple-Sparing Mastectomy.

Controversies persist regarding contraindications for nipple-sparing mastectomy (NSM). This study aimed to assess the accuracy of subareolar frozen section analysis and identify risk factors for nipple-areola complex (NAC) recurrence post NSM. Consecutive cases of primary invasive breast cancer undergoing NSM at our single center from January 2015 to December 2020 were retrospectively reviewed. The nipples were retained in 126 patients (127 breasts), and the areola was retained with nipple excision for five breasts. Frozen section analysis demonstrated a sensitivity of 81.8% and specificity of 95.3%. The NAC recurrence rate was 4.3% over a median follow-up period of 48 (30-105) months. An atypical ductal hyperplasia (ADH) at the margin emerged as an independent factor for NAC recurrence in multivariate Cox regression analysis (hazard ratio, 25.464; 95% confidence interval, 1.841-352.145; p = 0.016). Kaplan-Meier survival analysis revealed no statistically significant reduction in overall survival rates (log-rank test, p = 0.660). Frozen sections of subareolar tissue are reliable and re-excision may be necessary when ADH is detected at the nipple margin in NSM. The NAC recurrence rate was low, and the outcome was favorable following wide local excision.

Immediate Nipple Reconstruction With Areolar Flaps After Nipple Excision.

Nipple-sparing mastectomies (NSMs) have become a common surgical approach in the management of invasive breast cancers and ductal carcinoma in situ, and as a risk-reducing approach in genetically predisposed patients. The current standard of care in the management of positive nipple margin after NSM is total excision of the nipple-areola complex. In this article, we aimed to present a case series describing a novel approach to positive nipple margins with nipple-only excision and immediate nipple reconstruction using areolar flaps in patients who underwent NSM for noninvasive tumors. We conducted a retrospective review of patients who underwent NSM and were found to have positive nipple margins and underwent subsequent nipple excision with immediate areolar flap reconstruction. We identified 6 patients who underwent NSM and were found to have nipple margins-5 for ductal carcinoma in situ and 1 for invasive ductal carcinoma. These patients underwent nipple excision with immediate reconstruction using "sickle" flaps. We concluded that if nipple excision and immediate reconstruction with areolar sickle flaps can be performed, it results in good aesthetic outcomes without compromising oncologic results.

Nipple margin assessment at the time of nipple-sparing mastectomy.

Documenting negative margins at the nipple-areolar complex (NAC) during nipple-sparing mastectomy (NSM) remains the standard, but how to achieve this and how to manage a positive margin is debated. We sought to review nipple margin assessments at our institution and to analyze the risk factors of a positive margin and rate of local recurrence. Patients who underwent NSM between 2012 and 2018 were reviewed and divided into 3 groups based on indication - cancer, contralateral prophylactic mastectomy (CPM) and bilateral prophylactic mastectomy (BPM). Nipple-sparing mastectomies were performed on 337 patients; 72% for cancer, 20% for CPMs and 8% for BPMs. Nipple margin assessments were performed in 87.8% of patients; 10 patients (3.4%) had a positive margin, 7 of whom underwent NAC excision and 3 were managed with observation. As indications for NSM increase, assessment of nipple margin provides valuable information to manage the NAC in patients with cancer. The routine use of nipple margin biopsies in patients undergoing CPM and BPM may no longer be required, as rates of occult malignant disease are low with no positive biopsies. Further studies with larger sample sizes are needed.

Midterm follow-up results of a novel technique: Contralateral breast overlapped reconstruction after mastectomy for unilateral breast cancer

The breasts of Oriental women are characterized by an obvious scar constitution and a relatively small mammary gland volume. Thus, plastic surgery, which is now popular in the West, is not suitable for most patients in China, and Chinese surgeons are searching for symmetrical plastic surgery options that are suitable for patients with breast tumors, unilateral breast implants and an obvious scar constitution. Between January 2016 and December 2019, 15 patients underwent contralateral breast overlapped reconstruction (COBOR) at the Affiliated Hospital of Putian University. We assessed their clinicopathological data, complications, cosmetic satisfaction and quality of life. The mean age was 41.6 years (range, 31-54 years), the average BMI was 24.36kg/m2 (range, 20.3-28.4kg/m2), the most common tumor location was the upper outer quadrant (n=9), the mean preoperative tumor size was 21.11mm (range, 7-42mm), and 4 patients underwent neoadjuvant chemotherapy. The cancer grades and histological types were as follows: G3 nonspecial type (NST), 3 cases; G2 NST, 6 cases; G2 lobular carcinoma, 1 case; and ductal carcinoma in situ (DCIS), 5 cases. The nipple margin was negative in all of these cases. Among them, there was 1 case of poor wound healing caused by subcutaneous fat liquefaction around the incision. In another case, partial nipple necrosis occurred on the affected side due to an insufficient nipple blood supply after the operation and healed after debridement and dressing changes. There were no cases of tumor recurrence during the mean follow-up of 22.53 months (range, 11-47 months). The BREAST-Q scores showed that COBOR provided good patient satisfaction. For Oriental patients with small breasts, COBOR, which results in fewer scars, good symmetry and good satisfaction, is an effective and safe surgical method. However, larger studies with longer follow-up periods are needed to obtain more reliable postoperative results.

Increase in Utilization of Nipple-Sparing Mastectomy for Breast Cancer: Indications, Complications, and Oncologic Outcomes.

Nipple-sparing mastectomy (NSM) is increasingly performed for invasive breast cancer. Growing evidence supporting the oncologic safety of NSM has led to its widespread use and broadened indications. In this study, we examine the indications, complications, and long-term outcomes of therapeutic NSM. From 2003 to 2016, women undergoing NSM for invasive cancer or ductal carcinoma in situ (DCIS) were identified from a prospectively maintained database. Patient and disease characteristics were compared by procedure year, while complications were compared by procedure year using generalized mixed-effects models accounting for a random surgeon effect. Overall survival and time to recurrence were examined. Of the 467 therapeutic NSMs, 337 (72%) were invasive cancer, 126 (27%) were DCIS, and 4 (1%) were phyllodes tumors. Median age was 45years (range 24-75) and median follow-up among survivors was 39.4months. Three hundred and fifty-seven (76.4%) cases were performed in 2011 or after. When comparing NSMs performed before and after 2011, there was a significant increase in NSMs performed for invasive tumors (58% vs. 77%; p < 0.001). There was no difference in family history, genetic mutations, smoking status, neoadjuvant chemotherapy, prior radiation, nodal involvement, or tumor subtype. Twenty-one (4.5%) nipple excisions were performed, of which 14 were performed for cancer at the nipple margin. Forty-four breasts (9.4%) had complications that required re-operation. Fifteen patients had locoregional recurrence or distant metastasis. NSM use for invasive carcinoma has doubled at our institution since 2011, while postoperative complications and recurrence rates remain low. Our experience supports the selective use of NSM in the malignant setting with careful patient selection.

ASO Author Reflections: Management of the Nipple Margin After Mastectomy: A Trend Toward a more Minimally Invasive Approach.

ASO Author Reflections: Management of the Nipple Margin After Mastectomy: A Trend Toward a more Minimally Invasive Approach.

Nipple-sparing and skin-sparing mastectomy: Review of aims, oncological safety and contraindications

Skin-sparing (SSM) and nipple-sparing (NSM) mastectomies are relatively new conservative surgical approaches to breast cancer. In SSM most of the breast skin is conserved to create a pocket that facilitates immediate breast reconstruction with implant or autologous graft to achieve a quality cosmetic outcome. NSM is closely similar except that the nipple-areola complex (NAC) is also conserved. Meta-analyses indicate that outcomes for SSM and NSM do not differ from those for non-conservative mastectomies. Recurrence rates in the NAC after NSM are acceptably low (0–3.7%). Other studies indicate that NSM is associated with high patient satisfaction and good psychological adjustment.Indications are carcinoma or DCIS that require mastectomy (including after neoadjuvant chemotherapy). NSM is also suitable for women undergoing risk-reducing bilateral mastectomy.Tumor not less than 2 cm from the NAC is recommended, but may be less important than no evidence of nipple involvement on mandatory intraoperative nipple margin assessment. A positive margin is an absolute contraindication for nipple preservation. Other contraindications are microcalcifications close to the subareolar region and a positive nipple discharge.Complication rates are similar to those for other types of post-mastectomy reconstructions. The main complication of NSM is NAC necrosis, however as surgeon experience matures, frequency declines. Factors associated with complications are voluminous breast, ptosis, smoking, obesity, and radiotherapy.Since the access incision is small, breast tissue may be left behind, so only experienced breast surgeons should do these operations in close collaboration with the plastic surgeon. For breast cancer patients requiring mastectomy, NSM should be the option of choice.

The Oncological Safety of Nipple-Sparing Mastectomy: A Systematic Review of the Literature with a Pooled Analysis of 12,358 Procedures.

Nipple-sparing mastectomy (NSM) is increasingly popular as a procedure for the treatment of breast cancer and as a prophylactic procedure for those at high risk of developing the disease. However, it remains a controversial option due to questions regarding its oncological safety and concerns regarding locoregional recurrence. This systematic review with a pooled analysis examines the current literature regarding NSM, including locoregional recurrence and complication rates. Systematic electronic searches were conducted using the PubMed database and the Ovid database for studies reporting the indications for NSM and the subsequent outcomes. Studies between January 1970 and January 2015 (inclusive) were analysed if they met the inclusion criteria. Pooled descriptive statistics were performed. Seventy-three studies that met the inclusion criteria were included in the analysis, yielding 12,358 procedures. After a mean follow up of 38 months (range, 7.4–156 months), the overall pooled locoregional recurrence rate was 2.38%, the overall complication rate was 22.3%, and the overall incidence of nipple necrosis, either partial or total, was 5.9%. Significant heterogeneity was found among the published studies and patient selection was affected by tumour characteristics. We concluded that NSM appears to be an oncologically safe option for appropriately selected patients, with low rates of locoregional recurrence. For NSM to be performed, tumours should be peripherally located, smaller than 5 cm in diameter, located more than 2 cm away from the nipple margin, and human epidermal growth factor 2-negative. A separate histopathological examination of the subareolar tissue and exclusion of malignancy at this site is essential for safe oncological practice. Long-term follow-up studies and prospective cohort studies are required in order to determine the best reconstructive methods.

Positive Nipple Margins in Nipple-Sparing Mastectomies: Rates, Management, and Oncologic Safety

When a nipple margin of a nipple-sparing mastectomy (NSM) contains malignancy, current practice includes removal of the nipple or nipple areola complex (NAC). We evaluated rates and trends of positive nipple margins, subsequent management, and oncologic outcomes. A retrospective chart review of all NSM at our institution from 2007 to 2014 was performed. A descriptive analysis was performed of patients with positive nipple/subareolar margins. Among 1,326 NSM, 43 of 642 (6.7%) therapeutic and 3 of 684 (0.4%) prophylactic NSM had positive nipple margins. Nipple or NAC excision was performed for 39 of 46 (85%) positive nipple margins: 20 of 39 (51%) had nipple only and 19 of 39 (49%) had the entire NAC excised. Practice evolved to remove only the nipple and retain the areola for positive nipple margins: in 2007 to 2011, 7 of 17 (41%) underwent nipple-only excision compared with 14 of 22 (64%) in 2012 to 2014. Among 39 excised nipples/NAC, 28 (72%) contained no residual malignancy, while 8 contained ductal carcinoma in situ (DCIS), 2 had invasive lobular carcinoma, and 1 had invasive ductal carcinoma. With experience, rates of positive nipple margins for therapeutic NSM decreased from 11% (17 of 160) in 2007 to 2011 to 5.4% (26 of 482) in 2012 to 2014 (p < 0.05). At 36 month median follow-up, there were no recurrences in the nipple/NAC. Early results suggest that excision of the nipple with retention of the areola is a safe approach for management of a positive nipple margin after NSM. With experience, low rates of positive nipple margins are possible in therapeutic NSM. Overall risk of nipple/NAC recurrence after NSM remains extremely low.

Clinical efficacy of dual plane breast augmentation using perinipple incision

Objective To study the technology and the result of dual plane breast augmentation using nipple margin vertical incision of areola. Methods Totally 60 cases of augmentation mammaplasty were involved in this study. The nipple margin vertical incision of areola was applied obliquely into the breast through the pectoralis major fascia. The rib starting point of pectoralis major were cut off, medial to the side of the sternum. Under the pectoralis major the cavity was peeled according to the preoperative design range. Based on the different situation of the breast types Ⅰ, Ⅱ, Ⅲ, dual plane breast augmentations were stripped respectively. After implanting the breast prosthesis, the upper part of the prosthesis was under the pectoralis major and the lower part was under the mammary gland. Results The 60 patients were all after childbearing, 20 of whom underwent type 2 dual plane breast augmentation, 4 underwent type 3 double plane and the rest underwent type 1 double plane. After 3 months to 2 years follow-up, all cases got satisfactory results, except 1 case of postoperative hematoma and 1 case appeared capsular contracture. Conclusions The nipple margin vertical incision of areola can complete types Ⅰ, Ⅱ, Ⅲ dual plane breast augmentation operation, at the same time it can correct mild-to-moderate mastoptosis. Key words: Augmentation mammoplasty; Mammary areola; Perinipple; Incision

Pathological Evaluation of Nipple-Sparing Mastectomies with Emphasis on Occult Nipple Involvement: The Weill-Cornell Experience with 325 Cases

Nipple-sparing mastectomy (NSM) is an increasingly utilized surgical option in managing breast carcinoma; however, data on malignant involvement of a separately submitted nipple margin are scant. Consecutive NSM, including those performed for therapeutic and prophylactic purposes, over a 4-year period (2007-2011), were studied. A separately submitted nipple margin was evaluated by permanent H&E preparations and via frozen section evaluation whenever requested. 325 consecutive NSM specimens, 208 (64%) therapeutic-NSM, and 117 (36%) prophylactic-NSM were studied. All nipples were clinically unremarkable. 86% (179/208) of nipple margins from therapeutic-NSM and 100% (117/117) from prophylactic-NSM showed no histopathologic abnormality. 14% (29/208) of nipple margins from therapeutic-NSM and no nipple margin from prophylactic-NSM showed malignancy. Frozen section evaluation was performed in 188/325 NSM (58%) with a sensitivity of 64% and specificity of 99%. Central tumor location and stage N2/N3 lymph node status were significantly associated with nipple margin positivity (χ(2) ≤ 0.05). Subsequent nipple resection was performed in 69% (20/29) of nipple margin-positive cases with residual malignancy found in 40% (8/20, including three cases of invasive carcinoma). In a mean follow-up of 33 months, one invasive carcinoma recurred in the "saved" nipple, 36 months after therapeutic-NSM. 14% (29/208) of nipple margins in therapeutic-NSM and no nipple margin (0/117) in prophylactic-NSM showed malignancy. Central tumor location and N2/N3 stage were significantly associated with nipple margin positivity (χ(2) ≤ 0.05).

Nipple-Sparing Mastectomy for Breast Cancer and Risk-Reducing Surgery: The Memorial Sloan-Kettering Cancer Center Experience

Nipple-sparing mastectomy (NSM) has been gathering increased recognition as an alternative to more traditional mastectomy approaches. Initially, questions concerning its oncologic safety limited the use of NSM. Nevertheless, mounting evidence supporting the practice of NSM for both prophylactic and oncologic purposes is leading to its more widespread use and broadened indications. Using a prospectively maintained database, we reviewed our experience of 353 NSM procedures performed in 200 patients over the past 10 years. The indications for surgery were: 196 prophylactic risk-reduction (55.5%), 74 ductal carcinoma in situ (DCIS) (20.8%), 82 invasive cancer (23.2%), and 1 phyllodes tumor (0.5%). The nipple areolar complex (NAC) was entirely preserved in 341 mastectomies (96.7%). There were 11 patients (3.1%) who were found to have cancer at the nipple margin, warranting further excision. A total of 69 breasts (19.5%) had some degree of skin desquamation or necrosis, but only 12 (3.3%) required operative debridement, of which 3 breasts (1%) necessitated removal of a breast implant. Also, 6 patients (2%) were treated for infection. Of the 196 prophylactic NSMs, 11 specimens (5.6%) were found to harbor occult cancer (8 DCIS and 3 invasive cancers). One patient who underwent NSM for invasive ductal carcinoma in 2006 developed metastatic disease to her brain. No other recurrences are attributable to the 353 NSMs. The trends demonstrate the increasing acceptance of NSM as a prophylactic procedure as well as for therapeutic purposes. Although NSM is not standard, our experience supports the selective use of NSM in both prophylactic and malignant settings.